executed copy or facsimile of this instrument may act hereunder, and that revocation or
termination hereof shall be ineffective as to such third party unless and until actual notice or
knowledge of such revocation or termination shall have been received by such third party, and I
for myself and for my heirs, executors, legal representatives and assigns, hereby agree to
indemnify and hold harmless any such third party from and against any and all claims that may
arise against such third party by reason of such third party having relied on the provisions of this
instrument. This Special Power of Attorney may be revoked by me at any time.
(j) SIGNATURE AND ACKNOWLEDGMENT:
In Witness Whereof I have hereunto signed my name on __________________________,20___.
PRINCIPAL signs here:
==>___________________________________________________________
(ACKNOWLEDGMENT)
State of …………………………….)
) ss:
County of …………….....................)
On the ………..day of …………….in the year ………….before me, the undersigned, personally
appeared…………………………………………, personally known to me or proved to me on
the basis of satisfactory evidence to be the individual whose name is subscribed to the within
instrument and acknowledged to me that he/she executed the same in his/her capacity, and that
by his/her signature on the instrument, the individual, or the person upon behalf of which the
individual acted, executed the instrument.
……………………………………………………
………………………
Signature of Notary
Expiration Date
(k) SIGNATURES OF WITNESSES: By signing as a witness, I acknowledge that the
principal signed this instrument in my presence and the presence of the other witness, or that the
principal acknowledged to me that the principal’s signature was affixed by him or her or at his or
her direction. I also acknowledge that the principal has stated that this instrument reflects his or
her wishes and that he or she has signed it voluntarily. I am not named herein as a permissible
recipient of the principal’s benefits from a public retirement system.
_________________________________
___________________________________
Signature of witness 1
Signature of witness 2
_________________________________
____________________________________
Date
Date
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